Why is RT an area that is often inadequately supported by the medical record, which risks issues with reimbursement and compliance?
PDPM has certainly increased the post-acute industry’s focus on Respiratory Therapy. Providing RT for at least 15 minutes/day for 7 days during the lookback period enables RT to be coded on the MDS, Item O0400, and determines a Special Care High for the Nursing Component score.
It sounds simple. So why is RT an area that is often inadequately supported by the medical record, which risks issues with reimbursement and compliance?
How does your RT program measure up?
Are you able to ‘take a deep breath’ and sigh, knowing that your team’s delivery of RT services, documentation, and coding are compliant? Or are you ‘holding your breath’ and hoping that your team’s competencies and documentation are good enough to get by?
Let’s be in the position to be able to ‘take a deep breath’ and confidently know that your program is compliant!
“The Basics”
The RAI Manual provides the following definition of Respiratory Therapy:
“Services that are provided by a qualified professional (respiratory therapists, respiratory nurses). Respiratory therapy services are for the assessment, treatment, and monitoring of residents with deficiencies or abnormalities of pulmonary function. Respiratory therapy services include coughing, deep breathing, nebulizer treatments, assessing breath sounds, and mechanical ventilation etc., which must be provided by a respiratory therapist or trained respiratory nurse.”
A respiratory nurse must be proficient in the modalities listed above, either through formal nursing or specific training, and may deliver these modalities as allowed under the state Nurse Practice Act and under applicable state laws
“Things to Consider”
What type of training is required so my nurses may provide respiratory therapy in the SNF?
- The RAI Manual defines a respiratory trained nurse as one who has received education in delivering assessment and respiratory services through formal training or during nursing education. It is recommended that your facility references your state-specific Nursing Practice Act for guidance to determine specific training requirements for a respiratory trained nurse and to ensure your program’s regulatory compliance with the nursing scope of practice as defined by your state nursing board.
- It is essential that your nursing team is competent in providing respiratory interventions that comply with state regulations as well as meet the RAI Manual’s definition of a trained nurse. This can best be accomplished through a facility competency program provided at orientation and at least annually to ensure that your nurses are consistently delivering skilled respiratory interventions, completing pre and post-treatment assessments, and effectively documenting the intervention, to support coding Respiratory Therapy on the MDS.
- Does your facility utilize agency nursing staff? Consider requesting that the agency staffing company provides Respiratory Therapy competencies for the nurses who will be working at your facility. Ensure that these competencies are maintained in your facility’s staff education records from the onset for each nurse assigned to work at your facility.
Does your facility use contracted Respiratory Therapy services?
- Having contracted RT staff enables your facility to benefit from their specialized skill set, while allowing nursing to focus more time on other areas of resident care. It is imperative that the facility has a process in place to ensure that all RT documentation is completed at the time care is delivered, as not having RT documentation completed in the medical record in a timely manner may result in ineffectively coding RT on the MDS, thus not being able to capture the reimbursement for the RT services provided.
The Physician Order
- In order for RT to be coded on the MDS, a physician must order RT, which includes the frequency, duration, and scope of treatment, and be written prior to the initiation of services.
- Incentive spirometry should not be a blanket order.
- It is best practice for the physician to include the pulmonary condition and the medical necessity for RT intervention in their provider notes. Often, there is no evidence of why incentive spirometry or another RT intervention has been ordered, and including the clinical indication in the order and/or physician notes will justify the medical necessity for the RT intervention.
The Respiratory Evaluation
- A Respiratory Therapy evaluation must be completed by the respiratory therapist or respiratory nurse in order to initiate RT services. All RT services must be directly and specifically related to the written treatment plan that is based on this initial evaluation.
The delivery, documentation, and coding of RT
- The delivery of RT services must be required and provided by a Respiratory Therapist or a Respiratory Nurse and be reasonable and medically necessary for the treatment of the residents’ condition.
- It is recommended that the RT treatments be reported on the TAR. This should also include an assessment of the resident’s pre and post RT treatment, such as physical examination, Oxygen saturation, respirations, breath sounds, and presence of cough or sputum. The number of treatment minutes must also be recorded in exact treatment minutes.
- Per the RAI Manual, “only minutes that the respiratory therapist or respiratory nurse spends with the resident shall be recorded on the MDS. This time includes resident evaluation/assessment, treatment administration and monitoring, and setup and removal of treatment equipment. Time that a resident self-administers a nebulizer treatment without supervision of the respiratory therapist or respiratory nurse is not included in the minutes recorded on the MDS. Do not include administration of metered-dose and/or dry powder inhalers in respiratory minutes.”
- The number of days that RT was provided for 15 minutes will be recorded on the MDS, O0400D.
- The resident’s RT program should be assessed on a regular basis, with documentation of whether or not it is clinically appropriate for the prescribed interventions to be continued.
Is your facility underutilizing Respiratory Therapy services?
- The Journal of Managed Care and Specialty Pharmacy reported in a prior study that approximately 22% of nursing home residents had COPD and presented with concurrent diagnoses of asthma, dementia, CHF, pneumonia, or respiratory infection. Of the residents with COPD in this study, over 17% did not receive respiratory medications. The study suggests that nursing home residents with significant cognitive impairments may have difficulty utilizing handheld device formulations of respiratory medication and would better benefit from nebulized therapy.
- The study indicated that greater than 20% of the nursing home residents with COPD experienced 2 or more COPD exacerbations across the one-year study, as many as 60% were not receiving inhaled long-acting beta-agonist/corticosteroid combinations, and that significant use of short-acting beta-agonists monotherapy may be contributing to SOB, exacerbation and hospitalization in nursing home residents with COPD. This suggests that there is benefit in the facility’s careful and regular assessment of residents with COPD to ensure their symptoms are effectively managed.
- In addition to residents with a COPD diagnosis, it is recommended that those with other lung conditions, such as asthma, bronchiectasis, pneumonia, or COVID, and residents with recent chest or abdominal surgery, various neuromuscular diseases, rib fractures or requiring increased bed rest, also be considered for clinical benefits of incentive spirometry and other RT intervention.
